Probabilidad elevada de hospitalizacion por hipomagnesemia al combinar inhibidores bomba protones y diurético

Diedtra Henderson

September 30, 2014

Elderly patients taking proton-pump inhibitors (PPIs) were at a 43% increased risk of being hospitalized with hypomagnesemia, according to a population-based case control study. The risk was concentrated among patients taking both a PPI and a diuretic.

Jonathan Zipursky, MD, from the Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, and coauthors report their findings in an article published online September 30 in PLOS Medicine.

PPIs are the "mainstay" of treating acid-related disorders, Dr. Zipursky and coauthors write, with more than 147 million scripts for the medicines dispensed in the United States in 2010. In 2011, the US Food and Drug Administration issued a warning about a potential association between PPIs, but Dr. Zipursky and colleagues report that observational studies have provided conflicting outcomes.

Therefore, the researchers studied prescription records from April 1, 2002, to March 31, 2012, for all Ontario residents older than 66 years, looking at outpatient prescriptions for omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole. They included 366 patients who had been hospitalized for hypomagnesemia in the study, matching them with 1464 control participants.

"We found that current PPI therapy was associated with a 43% increased relative risk of hospitalization with hypomagnesemia in a large population of older outpatients," Dr. Zipursky and coauthors write. Specifically, the adjusted odds ratio was 1.43 for those taking PPIs compared with control participants (95% confidence interval [CI], 1.06 - 1.93).

When the investigators stratified patients according to diuretic use, they found that those patients receiving both a PPI and a diuretic had a 73% increased risk for hospitalization (95% CI, 1.11 - 2.70) compared with those receiving neither drug. In contrast, the risk among those taking a PPI but no diuretic was no longer statistically significant (adjusted odds ratio, 1.25; 95% CI, 0.81 - 1.91).

Shoshana J. Herzig, MD, MPH, an instructor in medicine at Harvard Medical School and a hospitalist researcher at Beth Israel Deaconess Medical Center, both in Boston, Massachusetts, told Medscape Medical News that the data were "compelling" and the findings "plausible," but added that limitations temper the study's conclusions.

"It's important that your case patients are really similar to your control patients," Dr. Herzig says. The control participants, however, were not hospitalized; hospitalized patients tend to be sicker. In addition, the researchers did not control for comorbidities.

"There is definitely the possibility of residual confounding," she told Medscape Medical News.

Patients prescribed diuretics are already losing magnesium, and PPIs "could tip the balance," she said. Clinicians should strongly consider discontinuing PPIs for these patients. In addition, physicians need to do a better job, in general, of evaluating the need for PPIs in patients whose symptoms have resolved. "There are a lot of people who get on these [medications] and stay on them," she said.

The research team was quick to note that their finding should not dampen appropriate prescribing of PPIs, nor did they argue in favor of routine screening for serum magnesium concentration. However, they did recommend clinicians consider alternate therapies for patients with hypomagnesemia who were currently prescribed PPIs.

"Future research may help further characterize the significance of this effect, and the importance of cumulative dose and duration of PPI therapy," Dr. Zipursky and colleagues write. "In the interim, we suggest that physicians recognize the potential causative role of PPIs in patients with hypomagnesemia, and reconsider PPI therapy in such patients."

The Canadian Drug Safety and Effectiveness Research Network and the Institute for Clinical Evaluative Sciences provided financial support for the study. One study author disclosed serving on advisory boards and/or receiving honoraria from AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Company, GlaxoSmithKline, Hoffman La Roche, Novartis, Novo Nordisk, and Pfizer. The other authors and Dr. Herzig have disclosed no relevant financial relationships.

PLoS Med. Published online September 30, 2014.

Revascularizamos todo en el momento agudo del infarto con elevación del ST?

Revascularizamos todo en el momento agudo del infarto?

ESC Congress 2014. El estudio, presentado en Barcelona, en el seno del congreso ESC 2014, con siglas CvLPRIT, aporta un diseño abierto, prospectivo y multicéntrico. Aleatoriza pacientes con infarto de miocardio con elevación del segmento ST cuando se detecta la enfermedad multivaso a tratar solo la arteria responsable (n=146) o a revascularización completa (n=150).

El criterio principal de valoración (MACE), es el combinado de mortalidad por todas las causas, IM recurrente, insuficiencia cardíaca o necesidad de revascularización (ICP o CABG) a los 12 meses. Los objetivos secundarios repasan variables de seguridad como accidente cerebrovascular isquémico confirmado, hemorragia intracraneal, hemorragia mayor no intracraneal, y complicaciones vasculares.

CvLPRIT incluyó 296 pacientes que ingresaron en siete centros de cardiología intervencionista del Reino Unido. Para aquellos pacientes en el grupo de revascularización completa, la arteria responsable del infarto se trató primero, seguido por las no responsables preferiblemente en la misma sesión, pero todas durante el ingreso en el hospital.

El estudio encontró que un año después del procedimiento, los pacientes en el grupo de revascularización completa tuvieron resultados significativamente mejores en comparación con los que tenían sólo se revascularizaba la responsable del infarto. Basado en una variable combinada de eventos cardiacos adversos mayores (MACE) que incluyen: mortalidad por cualquier causa, infarto recurrente, insuficiencia cardíaca y la revascularización motivada por isquemia (HR 0,45; p=0,009). Además, las diferencias entre los dos grupos se empezaron a vislumbrar pronto (con una p 0,055 a los 30 días).

Como era de esperar, el tiempo del procedimiento y el volumen de contraste fueron significativamente mayores en el grupo de revascularización completa en comparación con el tratamiento más simple (55 vs. 41 min, p<0,0001, y 250 vs. 190 ml, p<0,0001, respectivamente), pero a pesar de esto, los pacientes del grupo de revascularización completa no tuvieron aumento en las tasas de accidente cerebrovascular, hemorragia grave o de nefropatía inducida por contraste.

Los resultados CvLPRIT se correlacionan concordantemente con los del estudio PRAMI que fue presentado durante el congreso ESC del año pasado en Amsterdam y publicado en el New England Journal of Medicine. Así, los investigadores, liderados por el Dr. Anthony Gershlick (Hospital Glenfield, Leicester, Inglaterra) sugieren vehementemente que deben tratarse todas las lesiones antes de que se marche de alta el paciente.

Está claro que, de acuerdo con los investigadores, los resultados de CvLPRIT refuerzan los resultados PRAMI y fortalecen el argumento a favor de una estrategia de revascularización completa en el ámbito del ingreso hospitalario de un paciente.

B Bloqueantes, insuficiencia cardíaca y fibrilacion auricular

thelancet.com

Efficacy of β blockers in patients with heart failure plus atrial fibrillation: an individual-patient data meta-analysis
outline goes here

The Lancet, Early Online Publication, 2 September 2014
doi:10.1016S0140-6736(14)61373-8

Copyright © 2014 Elsevier Ltd All rights reserved.

Summary

Background

Atrial fibrillation and heart failure often coexist, causing substantial cardiovascular morbidity and mortality. β blockers are indicated in patients with symptomatic heart failure with reduced ejection fraction; however, the efficacy of these drugs in patients with concomitant atrial fibrillation is uncertain. We therefore meta-analysed individual-patient data to assess the efficacy of β blockers in patients with heart failure and sinus rhythm compared with atrial fibrillation.

Methods

We extracted individual-patient data from ten randomised controlled trials of the comparison of β blockers versus placebo in heart failure. The presence of sinus rhythm or atrial fibrillation was ascertained from the baseline electrocardiograph. The primary outcome was all-cause mortality. Analysis was by intention to treat. Outcome data were meta-analysed with an adjusted Cox proportional hazards regression. The study is registered with Clinicaltrials.gov, number NCT0083244, and PROSPERO, number CRD42014010012.

Findings

18 254 patients were assessed, and of these 13 946 (76%) had sinus rhythm and 3066 (17%) had atrial fibrillation at baseline. Crude death rates over a mean follow-up of 1·5 years (SD 1·1) were 16% (2237 of 13 945) in patients with sinus rhythm and 21% (633 of 3064) in patients with atrial fibrillation. β-blocker therapy led to a significant reduction in all-cause mortality in patients with sinus rhythm (hazard ratio 0·73, 0·67—0·80; p<0·001), but not in patients with atrial fibrillation (0·97, 0·83—1·14; p=0·73), with a significant p value for interaction of baseline rhythm (p=0·002). The lack of efficacy for the primary outcome was noted in all subgroups of atrial fibrillation, including age, sex, left ventricular ejection fraction, New York Heart Association class, heart rate, and baseline medical therapy.

Interpretation

Based on our findings, β blockers should not be used preferentially over other rate-control medications and not regarded as standard therapy to improve prognosis in patients with concomitant heart failure and atrial fibrillation.

ASPIRINA EN PREVENCION PRIMARIA. FDA APUNTA MAS CERCA

An Aspirin a Day? Only If You Have Had a Heart Attack

FDA issues recommendation against preventative low doses

By The Beating Edge Team | 5/12/14 1:01 p.m.

 

If you never have had any cardiovascular problems, the Food and Drug Administration (FDA) says you should not take aspirin to avoid a heart attack or stroke.
In a recommendation issued this week, the FDA says scientists have not proven aspirin therapy has any benefit for people without cardiovascular problems. This group includes those with risk factors such as a family history of heart disease.
At the same time, people taking aspirin every day face serious risks. These risks include developing dangerous bleeding into the stomach or brain.

People taking #aspirin every day may face serious #health risks #heartattack

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What if I have an existing heart condition?

If you have heart disease, such as a prior heart attack, bypass surgery or stents, everyone agrees that you should be taking a daily baby aspirin (81 mg) unless your doctor determines that you have a very high bleeding risk. For people without previous heart disease, aspirin is generally not recommended because bleeding in the brain or stomach can occur with daily aspirin use—even if you are taking coated aspirin.
For individual patients, your doctor will be able to calculate your risks and benefits from taking aspirin. Every heart condition is different and every patient’s situation is unique. Your doctor will need to know your medical history and weigh the risks.

Only for a select few 

When you have a heart attack, it’s because one of the coronary arteries, which provide blood to the heart, has developed a clot. The clot obstructs the flow of blood and oxygen to the heart.
Aspirin thins the blood, which makes it less likely to clot. The logic is that taking an aspirin a day helps prevent heart attacks.
Clinical data since the 1990s does show that a daily low dose of aspirin can help prevent a re-occurrence for people who have had a heart attack, stroke or disease of the heart’s blood vessels, the FDA says.
But only a select few patients benefit from aspirin therapy – even among those who have had cardiovascular problems.
The patient who would benefit from aspirin therapy is someone who has every risk factor: high blood pressure, high cholesterol, strong family history, diabetes, smoking. Among patients with all of these risk factors, some of them we will treat with aspirin. But it’s not very many.

Bleeding common

Internal bleeding, especially in the stomach, is quite common with daily aspirin use.
So if you have a low risk of a heart attack, the bleeding risk may overwhelm any potential benefit of aspirin.
The recommendation came on the heels of the FDA denying a request from Bayer. The drug manufacturer asked to change its aspirin packaging to say consumers could use aspirin as a prevention measure, even if they have not had a heart attack, stroke or cardiovascular problems.
You should stop taking aspirin if you’re taking it without a doctor’s guidance to prevent cardiovascular problems and have no history of heart disease or heart attack.

Don’t self-medicate

Above all, talk with your doctor.
Frankly, self-medication is almost never a good idea, whether it’s aspirin or anything else.
The FDA recommendation applies to doses ranging from 81 milligrams in a low-dose tablet to the 325 milligrams in a regular-strength tablet.
For patients with a history of cardiovascular problems, the FDA says your doctor should tell you the aspirin dose and frequency that will provide the greatest benefit with the least side effects.